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Setting up a Covid-19 vaccination programme for immunocompromised patients

On 1st September 2021 the JCVI  recommended that certain patients aged 12 and over, who were thought to be immuno-suppressed (through disease or medication) around the time of their first two doses of Covid-19 vaccine, should be offered a third primary dose 8 weeks after their second dose. There has been considerable confusion about these third primary doses as they are different from the booster doses that many people who are now over 6 months after their second dose are being offered. Many patients have reported they have been unable to obtain their third primary dose; or have only obtained after a lengthy dialogue with NHS clinicians and managers.

Here are the steps that could be followed to safely implement the third primary vaccine dose programme for immunocompromised patients in England’s NHS.

  1. Identify your target population. This is an essential first step in any vaccination programme (or in any public health programme). Identifying the target population requires searching NHS medical records held by hospitals and general practices.
  2. Clinical diagnoses (such as renal transplant) have to be turned into lists of clinical codes. This requires collaboration between hospital doctors, GPs, other health professionals and health informatics specialists to produce the code lists based on the ICD-10, SNOMED and Read clinical codes that are used by NHS organisations.
  3. Patients need to be identified who were prescribed medications around the time of their first two doses of Covid-19 vaccine that have been identified by the JCVI and specialist groups as possibly leading to a weaker response to their vaccinations. This might not be possible for GPs to do if they did not prescribe the medication themselves as is the case for many specialised drugs used for these patients.
  4. There needs to be adequate consultation with organisation such as NHS Digital, general practices, primary care networks, specialist medical societies, and patient organisations (for example, Versus Arthritis, Blood Cancer UK, Crohn’s & Colitis UK and Kidney Care UK amongst others).
  5. Once an agreed form of words and a unified approach have been reached, there should be a clear public health announcement via reputable sources, and NHS web pages available with clear easy to understand information and FAQs for clinicians, patient support organisations and the public. Clinicians and their teams should ideally be made aware of any announcements from NHS England before the public so that they are able to answer queries from patients, parents and carers.
  6. Those working at NHS 119, vaccine sites or the national covid-19 vaccine call centres must be fully briefed and updated on significant changes before any announcements are made, so that patients calling with queries or to book their Third Primary Doses are not met with a confused response and a lack of a clear process on how to access their vaccines (which damages public trust and confidence, and increases vaccine hesitancy).
  7. Programmes that use clinical codes to search NHS medical records have to be written. These require testing and debugging to make sure they work correctly on each different clinical record system used by the NHS. The NHS does not have a unified electronic medical record system and individual NHS Trusts and general practices will have different systems. These programmes need to be written centrally wherever possible to prevent local areas producing their own versions that may differ from each other and thus not identify patients correctly. This is more straightforward for general practices than hospitals because most general practices mainly use of one two electronic medical record systems (EMIS or SystmOne). The situation is more complex in NHS hospitals because of the many different IT systems used.
  8. Once the programmes are written, they need to be run by local NHS teams as it seems that NHS England is not yet able to run these searches centrally for all of England. In the case of general practices, local CCGs or GP Federations should be able to run the searches to identify patients. Hospitals will also need to run searches to identify eligible patients. The NHS should also make use of National Disease Registers, such as the NHS Blood and Transplant registry, for patient identification wherever possible.
  9. The list of patients generated by the programmes have to be cleaned to remove duplicates and any patients identified in error. Patients who may be unsuitable for vaccination such as the extremely frail or terminally ill need to be removed from the lists. Local NHS teams also need to consider how they approach patients who may have previously refused vaccination.
  10. Patients then need to be contacted about the vaccinations. Most general practices are no longer involved in the Covid-19 vaccination programme. These invitations therefore need to come from organisations that are offering Covid-19 vaccines. This might include hospital clinics, NHS vaccine centres, or GP-led vaccine hubs in areas where GPs are still offering Covid-19 vaccines.
  11. IT systems that record Covid-19 vaccinations (such as Pinnacle) need to be able to record the third primary dose correctly; so that it is not recorded as a standard booster dose or as another first or second dose. This ensures the patient’s vaccination status is accurate, that audits can be done accurately and that recalls can be generated for a booster in 6 months. Details of the vaccination also needs to be uploaded correctly into the patients’ usual electronic health record.
  12. The NHS app needs to correctly display that this is indeed a third primary dose, and that the patient is fully vaccinated; and IT systems need to ensure that the patients can then also be invited for their booster dose (effectively, a fourth vaccine dose for this special group of patients) in due course (typically likely to be six months after the third primary dose). A system for recording vaccines given abroad should also be made available.
  13. Please remember that in most parts of England, your general practice cannot offer you a Covid-19 vaccine or book you an appointment for one. In these circumstances, NHS 119 or your local NHS Covid-19 vaccine centre need to do this. To make access to vaccinations easier for patients, the NHS should ensure that a large number of locations are offering vaccinations so that patients can receive these close to home and do not have to travel long distances. Arrangements for vaccination also need to be made for the residents of care homes and for people who are housebound.
  14. NHS medical records are not always accurate or up to date. Each local area needs to have a named person who patients can contact if they feel they have been missed off the list incorrectly; or to help patients who continue to have any difficulties booking appointments.
  15. In order to provide a booster (fourth) dose for this group after six months, around April 2022, NHS IT systems need to be accurate and record third primary doses correctly and not as booster doses. This will ensure that this vulnerable group of patients do not experience further difficulties or delays in booking these appointments.

All these steps could have been better planned and communicated by NHS England; which would have made the process clearer for frontline NHS staff; as well as making it easier and less stressful for patients to receive their third primary Covid-19 vaccine dose. A well-planned and implemented vaccine programme maintains confidence in the vaccine programme which may reduce vaccine hesitancy, and helps patients and clinicians alike, improving vaccine uptake and reducing pressures on the NHS. It is essential that the problems experienced by immunocompromised patients in accessing their third primary Covid-19 vaccine doses are not repeated, appropriate lessons learned and steps taken by NHS England to ensure accurate recording of vaccinations and recall for future vaccinations for our most vulnerable patients.

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, 

Simon Hodes, NHS GP Partner, Watford, UK and private general practitioner at the Cleveland Clinic London.

Fiona Loud, Policy Director, Kidney Care UK, Twitter

Liz Lightstone, Professor of Renal Medicine, Imperial College London, Twitter

This article was first published in BMJ Opinion.

Covid-19 vaccines: patients left confused over rollout of third primary doses

How a society treats its most vulnerable is always the measure of its humanity is a well-known quote often attributed to Mahatma Gandhi. With the “levelling up” agenda being quoted widely by the UK government, and the effects of pre-existing health inequalities never more exposed than by the covid-19 pandemic, we all need to focus on the health of the most vulnerable in society. Our highest risk patients, and their household members, were rightly prioritised for covid-19 vaccination at the start of the rollout programme in December 2020.

Early in the pandemic, the UK government recognised that certain patients with complex medical conditions, or who were immuno-suppressed through disease or medication, would be most at risk from the complications of covid-19. These patients were advised to take careful infection control precautions, and were classed as clinically extremely vulnerable” (CEV). Among the advice given to them was to “shield” and to facilitate this, they were added to a “Shielding Patients List” (SPL) at their GP practices. Despite GP practices having robust disease registers and arranging seasonal flu vaccine recalls annually for mostly similar patients, NHS England decided to create centrally generated lists for CEV, and sent out letters to these patients.

Unfortunately, NHS Digital wrote to many patients who probably should not have been included as CEV (for example those with a history of glandular fever; or with long resolved and fully treated cancers in full remission), and also failed to include many patients who should have been classed as CEV. At the time, a survey by Pulse reported that after assessing the list of shielded patients provided by NHS England, on average practices had to remove 30 patients from the list, while adding 53 patients who had been missed off.

GP teams nationwide spent many hours scrutinising these lists, using their electronic notes, disease registers, and personal patient knowledge. The list of CEV patients needed to be as accurate as possible to try to ensure that the most vulnerable were protected, pending the arrival of covid-19 vaccines.

The importance of the accuracy of these lists cannot be overemphasised. These patients were offered extra support from the government, and local volunteers such as regular check-up calls from social prescribers at GP practices and both the patients and their household members were prioritised for vaccines. The social and mental health impact of shielding has also been noted in practice and widely reported. When the Joint Committee on Vaccination and Immunisation (JCVI) announced the hierarchy of priority groups for vaccination, there was much debate about how high up the priority list CEV patients should be, with many surprised that they were left to be sixth in line, with priority for vaccination largely being determined by factors such as residential setting, health and social care occupation, and age.

We are now offering covid-19 vaccine boosters for many people who are over six months after their second dose. The JCVI also announced on 1 September 2021 that certain patients aged 12 and over, who were immuno-suppressed (through disease or medication) around the time of their first two doses, should be offered a third primary dose after eight weeks from their second dose. Once again, as seems to be a recurring theme throughout the pandemic, this process has been poorly announced with the media reporting it before healthcare professionals were instructed about the process; and without a clear plan for implementing the programme.

Our most vulnerable and naturally anxious patients are confused about who should be recalling them for a third primary dose, whether or not they will be given a booster (in effect their fourth vaccine) six months later, and where to access their vaccines. Kidney Care UK for example has been deluged with enquiries from patients, many of whom have tried calling the national NHS 119 helpline to find that the staff there are often unaware of the process for arranging third primary doses. Although the JCVI wrote to specialists on 2 September 2021, it clearly takes time to review notes, run searches, and contact patients, with many patients now contacting their GP practices for support and advice. Furthermore, many of these immune-suppressed patients may receive their medication from hospital clinics, and thus might not easily show up on medication searches in their general practices.

To add further complications, the software used (called Pinnacle) to record covid-19 vaccines is not yet able to recognise a third primary dose, so they are currently being recorded as boosters, which is technically not correct. This will make any audits of vaccine uptake in this group extremely challenging, and may cause confusion in the future. In addition, patients are reporting that their third primary doses are not displayed correctly on their NHS app, presumably for the same reason. Once again, this highlights the need for joined up thinking before rolling out plans. It is worth noting that GPs add seasonal flu vaccines on our fully electronic patient records (which are later uploaded to Pinnacle), but the covid vaccines have to be added on Pinnacle only (which is later uploaded to GP-held electronic medical records and the NHS app). This is the reverse of what we would expect and is once again an example of NHS staff being forced to adapt to IT systems rather than the IT systems being designed to support NHS staff in their day-to-day work.

The government must look at how they communicate with both the public and professionals to ensure that our ongoing covid-19 vaccination programme is fit for purpose, and maintains the trust of the public to ensure high take up and prevent vaccine hesitancy. Unfortunately, after a promising start, the UK has slipped down the covid-19 vaccination league tables, and we are becoming an international covid-19 hotspot because of our high infection rates. The covid-19 vaccination programme has allowed us to come out of lockdown, and its ongoing success will depend on public confidence and effective messaging from the centre. As we enter the winter, with many other non covid-19 seasonal infections already in circulation, it is crucial that we try to protect our most vulnerable in society by making our vaccination programme as easy as possible for patients to access and navigate.

Simon Hodes, GP Partner Watford, Twitter: @DrSimonHodes

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.

Covid-19 treatments and vaccines must be evaluated in pregnancy

The numbers of pregnant and postpartum women in the UK admitted to hospital or intensive care because of Covid-19 peaked over the summer of 2021 Maternal mortality has reached concerning levels in 2021, with case fatality rates rising in the US, doubling in Brazil, and almost tripling in India since the beginning of the pandemic. In Brazil, health officials even suggested avoiding pregnancy to reduce risk during the pandemic.

Inconsistent messaging from authorities, driven by lack of trial data, has increased Covid-19 vaccine hesitancy among pregnant women. This, coupled with the increased transmissibility of new variants and relaxing of social distancing restrictions, contributed to the surge in hospital admissions seen in successive waves. Concerns around the longer term effect of Covid-19 post partum, including long Covid, cardiovascular complications of covid-19, and widening socioeconomic disparities are also mounting. Despite a desperate need for treatments, pregnant women continue to be left behind.

The full article can be read in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.n2377

Covid-19 vaccination in children, adolescents, and young adults: how can we ensure high vaccination uptake?

After a rapid start, the pace of the United Kingdom’s (UK) covid-19 vaccination programme has slowed down while the UK still faces high infection, hospitalisation, and death rates, and a more transmissible Delta SARS-CoV-2 variant. Now that vaccination of children aged 12-15 has started, it is essential to achieve a high uptake of vaccination in this group, and also in young adults, to both protect them and to move the UK closer towards population level immunity. [1,2] Despite two doses of Pfizer-BioNTech, Moderna, and AstraZeneca vaccines offering good protection against the Delta variant—with Pfizer-BioNTech and AstraZeneca vaccines between 92-96% effective in preventing hospitalisations—many young people remain unvaccinated by choice, raising their risk of infection, hospitalisation, and long-term complications from covid-19. [3-5]

The UK population is among the most willing to receive a covid-19 vaccine; as of 11 October 2021, over 49 million individuals (85.6% of people aged 16 and over) had received at least one dose of a covid-19 vaccine. [6,7] However, the covid-19 vaccination programme—the largest ever launched by the NHS—is reaching a “demand” ceiling in adolescents and young adults, finding itself well behind other Western European countries, and hampering efforts to achieve population level immunity. If vaccination uptake is also slow in 12-15 years old children, this will further hinder efforts to reach population immunity.

Vaccination rates in younger people are lower and increasing more slowly than was seen in older age groups when they were first offered vaccination. [1,8] According to the Office for National Statistics, 14% of those aged 16-17 years, 10% of those aged between 22-25 years, and 9% of those aged between 18-21 years consider themselves “hesitant” compared to 4% observed across all other age groups. [5] This mirrors concerning findings from the USA which demonstrate that one in four of those aged between 18 and 25 “probably will not” or “definitely will not” receive a covid-19 vaccine, despite their heightened infection risk in recent months. [9] Given their increased tendency to socialise, strategies that improve vaccine acceptance in adolescents and young adults remain essential to control the pandemic globally as well as in the UK. [10]

Historically, vaccine hesitancy exists on a spectrum and is listed by the WHO as one of the top 10 global health threats. [11] The groups that are among the currently most affected by the virus are also the ones with the lowest vaccination rates. [12] With ideal conditions for SARS-CoV-2 to spread, the risk of emergence of “super variants” that could potentially escape vaccines and jeopardise the health of the most vulnerable in society remains a risk. Vaccine hesitancy in young people in the UK may be further increased by the delay in approving vaccination for 12–15 year-olds, with the UK starting vaccination later than many other European and North American countries. The message from the UK’s Joint Committee on Vaccination and Immunisation (JCVI) that covid-19 vaccination in this group offers only “marginal benefits” will also have contributed to this, with many parents and children questioning why they should be vaccinated if this is the case. [13] The benefits and potential risk from vaccination will therefore need to be discussed carefully with children and their parents to dispel any unwarranted negative views. [14]

This has been successfully done in Portugal; despite Portuguese parents not being safe from vaccine misinformation and disinformation, the country has managed to emerge as the world’s vaccination front-runner, with 86% of its population vaccinated (98% of whom are aged 12 years and over). [15] Its successful vaccine rollout is, in part, attributed to the country’s comprehensive monitoring system; vaccine compliance is monitored nationally by healthcare facilities, schools, daycare centres, summer camps, and other child institutions, allowing the country to develop and tailor educational information to hesitant parents or parents known to have refused a vaccine in the past. [16] This has generated favourable conditions for paediatric immunisation across the country.

Concerns about side effects are an important factor in vaccine hesitancy in children, adolescents, and young adults, particularly the risk of condition such as myocarditis. [9] Although rare, the myocarditis and pericarditis reports in adolescents and young adults, following the administration of Pfizer-BioNTech and Moderna vaccines, will have amplified fears of vaccines in this group. [17] However, the risk of developing complications, such as blood clots and myocarditis, from covid-19 illness remains greater than the risk from vaccines. [18] Genuine concerns about the side effects of vaccines should be addressed by academics and clinicians proactively listening to young people, and sharing risks and benefits in a manner that aligns intention with action. [19] It is also essential that moving forwards, the UK’s covid-19 vaccination programme is embedded in primary care to create a cost-effective, sustainable infrastructure for vaccine delivery; and to avoid making the many mistakes that were made in other parts of the covid-19 response, such as Test and Trace and the Nightingale Hospitals. [20]

To offset optimistic bias, including adolescents and young adults perceiving the risk of disease being lower than the risk of receiving a covid-19 vaccine, communication should speak to mechanism of action, effectiveness, and safety relevant to these age groups and the wider societal benefits of vaccination in protecting their older family members, and vulnerable friends and colleagues. [10,21] Further, public health messaging will be more effective if the benefits of controlling the pandemic, including freedom to attend festivals, sporting events and entertainment venues, as well as the ability to travel are reinforced. Targeted health messaging and public education campaigns will also require harnessing social media, schools and universities to counter the covid-19 infodemic. [10] To increase vaccination rates, messages should be tailored for families financially burdened by the pandemic, families with lower parental education and incomes, and adolescents and young adults with adverse childhood experiences. [10]

While the risk of severe disease and death from covid-19 is lower in young people, high infection rates and low vaccination rates mean this group remains vulnerable to long covid and its debilitating symptoms, regardless of the symptoms shown during their covid-19 infection. [9] With the majority of covid-19 deaths occurring in those aged 75 years and over throughout the pandemic, a youthful sense of invincibility will be an important barrier to overcome; young adults need to be mindful that although their symptoms may not be as severe, 57%, 39% and 30% of individuals have stated that long covid has negatively impacted their wellbeing, ability to exercise and ability to work, respectively. [22,23] Recent evidence suggests more people expressed fear and concern about the risk to health of those close to them. [24] Therefore, emphasising the protection that vaccines offer to those particularly vulnerable will likely have a positive effect on adolescents and young adults and their parents.

The pandemic is a “collective action problem,” requiring personal responsibility and responsible communication by governments and public health authorities that break through optimistic bias without prompting feelings of anxiety. The UK’s mixed messages on mitigation measures including face masks and working from home are likely to provide a false sense of security that discourages vaccination uptake at a time when infection rates remain much higher in the UK than other European countries. The race between vaccinations and mutations requires consistent, clear, and data-based messages that dispel misinformation, and promote informed decision-making, civic awareness, voluntary cooperation and a sense of collective purpose. This will improve vaccine uptake in all sections of the population, including children, adolescents, and young adults, at a key time when vaccination is being extended in many countries to younger age groups.

Tasnime Osama, Honorary Clinical Research Fellow in Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @itasnimeo

Mohammad S Razai, NIHR In-Practice Fellow in Primary Care, Population Health Research Institute, St George’s University of London. Twitter @MohammadRazai

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed

Competing Interests: None declared. 

Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. MSR is funded by the NIHR as an In-Practice Fellow. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

This article was first published by BMJ Opinion.

References:

  1. GOV.UK. Vaccinations in the UK 2021 doi: Available from: https://coronavirus.data.gov.uk/details/vaccinations
  2. CIDRAP. Youth, Delta variant behind UK COVID surge. 2021 doi: Available from: https://www.cidrap.umn.edu/news-perspective/2021/06/youth-delta-variant-behind-uk-covid-surge
  3. Yale Medicine. Comparing the COVID-19 Vaccines: How Are They Different? . 2021 doi: Available from: https://www.yalemedicine.org/news/covid-19-vaccine-comparison
  4. GOV.UK. Vaccines highly effective against hospitalisation from Delta variant. 2021 doi: Available from: https://www.gov.uk/government/news/vaccines-highly-effective-against-hospitalisation-from-delta-variant
  5. Office for National Statistics. Coronavirus and vaccine hesitancy, Great Britain: 26 May to 20 June 2021. 2021 doi: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandvaccinehesitancygreatbritain/26mayto20june2021
  6. Imperial College London. Covid-19: Global attitudes towards a COVID-19 vaccine. 2021
  7. GOV.UK. Daily summary. Coronavirus in the UK. 2021 doi: Available from: https://coronavirus.data.gov.uk/
  8. Publich Health England.  COVID-19 vaccine surveillance report – week 29. 2021
  9. S. Leigh. Vaccine Hesitancy in Young Adults May Hamper Herd Immunity. UC San Francisco. . 2021 doi: Available from: https://www.ucsf.edu/news/2021/07/420991/vaccine-hesitancy-young-adults-may-hamper-herd-immunity
  10. Afifi TO, Salmon S, Taillieu T, et al. Older adolescents and young adults willingness to receive the COVID-19 vaccine: Implications for informing public health strategies. Vaccine 2021;39(26):3473-79.
  11. World Health Organization. Ten threats to global health in 2019. 2019 doi: Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
  12. Public Health England. SARS-CoV-2 variants of concern and variants under investigation in England 2021
  13. Salisbury H. Helen Salisbury: Official hesitancy is not helping. bmj 2021;374
  14. Majeed A, Hodes S, Marks S. Consent for covid-19 vaccination in children. bmj 2021;374
  15. The New York Times. In Portugal, There Is Virtually No One Left to Vaccinate 2021 doi: Available from: https://www.nytimes.com/2021/10/01/world/europe/portugal-vaccination-rate.html
  16. Fonseca IC, Pereira AI, Barros L. Portuguese parental beliefs and attitudes towards vaccination. Health Psychology and Behavioral Medicine 2021;9(1):422-35.
  17. Centers for Disease Control and Prevention. Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination. 2021 doi: Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html
  18. Oxford University. Risk of rare blood clotting higher for COVID-19 than for vaccines 2021 doi: Available from: https://www.ox.ac.uk/news/2021-04-15-risk-rare-blood-clotting-higher-covid-19-vaccines
  19. Dubov A, Phung C. Nudges or mandates? The ethics of mandatory flu vaccination. Vaccine 2015;33(22):2530-35.
  20. Hodes S, Majeed A. Building a sustainable infrastructure for covid-19 vaccinations long term. bmj 2021;373
  21. Razai MS, Chaudhry UA, Doerholt K, et al. Covid-19 vaccination hesitancy. bmj 2021;373
  22. Office for National Statistics. Coronavirus (COVID-19) latest insights: Deaths. 2021 doi: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19latestinsights/deaths
  23. Office for National Statistics. Coronavirus and the social impacts of ‘long COVID’ on people’s lives in Great Britain 2021 doi: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronavirusandthesocialimpactsoflongcovidonpeopleslivesingreatbritain/7aprilto13june2021
  24. Antonopoulou V et al. Which factors may help increase COVID-19 vaccine uptkae in England? . 2021 doi: Available from: https://research.ncl.ac.uk/behscipru/outputs/policybriefings/PRU-PB-011%20PRU%20covid%20vaccine%20policy%20brief%20study%204%20300421.pdf

Be aware of the overlap in symptoms between colds and Covid-19

During the previous winter (2020-21), rates of colds, flu and other respiratory infections were very low across the UK because of social distancing and other infection control measures. Now that these measures have largely stopped, we are seeing an increase in respiratory infections.

The symptoms of a cold can typically include a blocked or runny nose, sore throat, headache, cough , loss of smell, sneezing and muscle aches. Many of these symptoms can also occur in people with a Covid-19 infection. Now that most adults in the UK have been fully vaccinated with two doses of a Covid-19 vaccine, when people do contract Covid-19, it is often with milder symptoms that can overlap those from a cold. This means that for many people with these kinds of symptoms, a Covid-19 test will be needed to separate the two conditions.

There will be a lot of scope to confuse the symptoms of colds and Covid-19 during the winter. The message for the public should be to always be cautious if you have symptoms of a cold, get a test when appropriate, and limit interactions with people outside your household until you are better.

You can read more about this issue in this Daily Mirror article.

Patient-initiated second medical opinions in healthcare

A second medical opinion is a medical decision-making tool for patients, physicians, hospitals and insurers. For patients, it is a way to gain an additional opinion on a diagnosis, treatment or prognosis from another physician. Physicians seeking another colleague’s opinion may refer a patient to another consultant to gain further advice. Many health insurers mandate second opinion programmes to reduce medical costs and eliminate ineffective or suboptimal treatments. Hospitals may also require second reviews as part of routine pathology, radiology reviews or for legal purposes. consultant to consultant referrals. Patients in primary care may also request an opinion from a second specialist when unhappy with the opinion from the first specialist.

We carried out a systematic review to summarise evidence on (1) the characteristics and motivating factors of patients who initiate second opinions; (2) the impact of patient-initiated second opinions on diagnosis, treatment, prognosis and patient satisfaction; and (3) their cost effectiveness. The reivew was published in BMJ Opinion.

Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions.

The review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-044033

Will the NHS survive without GPs?

That rhetorical questions like the recent one posed by some in the media are even asked shows how deeply ill-informed and distorted the discourse on healthcare has become in the UK. Any dispassionate observer would know that GPs are the bedrock of the NHS; and without GPs the NHS will collapse. Here are just a few home truths: GPs in England manage a wide array of acute and chronic health conditions through over 300 million patient consultations each year compared to 23 million A&E visits. [1] GPs issue about one billion prescriptions annually and have delivered two thirds of phase 1 covid-19 vaccinations. [2]

The public already know how hard their family doctors are working to care for them. Despite the challenges of the pandemic, soaring demand, a shrinking GP workforce and a workload that has often become unmanageable, GPs have one of the highest public satisfaction ratings of any public service in the UK. In a survey in July 2021, an overwhelming majority of patients (83%) rated their overall experience of GPs as good and 48.2% rated their experience as “very good.” [3] By contrast, in a comparable UK survey of adult hospital inpatients for overall experience in 2019, 48% of patients gave a score of 9 or 10 (good or very good).

General Practitioners are highly skilled professionals who manage extremely complex medical conditions with limited access to resources, including high-tech diagnostics, available in secondary care. GPs not only treat medical conditions, but through their longitudinal and relationship-based care, also manage non-medical problems. One in five patients consults general practitioners for primarily social problems rather than medical. [4]

Much of the reputation of the NHS in international league tables (ranked number one health system out of 11 countries in 2017 and fourth in 2021) rests on the efficiency and excellence of its primary care. [5,6] A year’s worth of GP care per patient costs less than an A&E visit and less is spent on general practice than on hospital outpatients. GP practices were paid an average £155 per patient in 2019/2020, but the average cost of treatment in A&E, without the cost of ambulance or overnight admission, could be up to £400. Yet for the past two decades funding for hospitals has grown twice as fast as for general practice. [1] Further, between 2005/6 to 2017 the proportion of money spent in general practice fell from 9.6% to 8.1%.

Recent surveys show two in three patients (67%) are satisfied with the appointment times available to them and 67% find it easy to get through to GPs. [3] General practice had to quickly adapt during the pandemic to provide safe care by fulfilling their public health role in protecting their patients and the community from covid-19. More patients now consult in primary care than the pre-pandemic with over half these appointments face to face. [7] There are however serious problems and challenges that patients face including access to GP services and the quality of their care.

The public deserves honesty and courage from political leaders, commentators, and policymakers. Rather than skirting over facts by blaming GPs, who currently deliver over 31 million appointments per month in England, politicians need to be honest with the public on what kind of healthcare the population needs and what they are currently getting.

The UK spends less per capita on healthcare than other comparable countries (0.27% of GPD compared to an OECD average of 0.51%). [8] The UK also has one of the lowest numbers of doctors in leading European countries relative to its population, behind Estonia, Slovenia, and Latvia (about 2.9 per 1,000 people, compared with an average of 3.5 doctors across the OECD). The OECD figure also includes hospital doctors which have grown. In England, between 2004 and 2021 the number of hospital consultants has risen by 83% (from 28,141 to 51,490). On the other hand, the number of permanent and locum qualified GPs in England has fallen with fewer GPs in December 2020 than the year before. The Nuffield Trust analysis shows the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s with the shortage particularly marked in some English regions.

Lack of an adequate GP workforce is only part of the problem. The recent media attacks on GPs highlights a total disregard for a workforce already at breaking point. A record number of GPs are seeking mental health counselling, and many are leaving the workforce by taking early retirement or working abroad. Therefore, the question that we must ask is: if the NHS collapses, who will notice it? Those with platforms to undermine the NHS will be unlikely to notice it. The elite has the means and resources to seek healthcare outside the NHS and even abroad, but for everyone else the collapse of the system will be catastrophic.

The solution starts with putting a stop to attacks on GPs and the NHS by politicians and the permanently outraged sections of the media. Secondly, to achieve health outcomes comparable to other OECD countries, the NHS must tackle workforce shortages and the decline in quality of services. [9] The increasing health needs of an ageing population and the growing demand for better healthcare require more than alienating and undermining a workforce on whom the NHS depends. General practice could make better use of non-medical professionals such as social prescribers to reduce the workload and people could be sign-posted to services in the community without a GP referral. The administrative burden on primary care is also unsustainable and must be reduced; for example, by suspending CQC inspections. We also need a dialogue between the public, professionals, and politicians about what kind of primary care system they want in the UK; with plans then backed up with the appropriate level of investment. Health systems with a strong primary care infrastructure can achieve better health outcomes, improve patient experience, and reduce pressures elsewhere in the NHS. This should be the objective that we strive to achieve.

Mohammad Sharif Razai, NIHR In-Practice Fellow in Primary Care, St George’s University of London. Twitter: @mohammadrazai

Azeem Majeed, Professor of Primary Care & Public Health, Department of Primary Care & Public Health, Imperial College London @Azeem_Majeed

This article was first published in BMJ Opinion.

References:

  1. NHS England. Primary Care. Available from: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/ (accessed 19 September 2021)
  2. Patient Information. Where to get medication in an emergency. Available from: https://patient.info/news-and-features/where-to-get-medication-in-an-emergency (accessed 19 September 2021)
  3. NHS England.  GP Patient Survey 2021. Available from: https://www.england.nhs.uk/statistics/2021/07/08/gp-patient-survey-2021/ (accessed 19 September 2021)
  4. Advice Services Alliance. The role of advice services in health outcomes: evidence review and mapping study. 2015. https://www.thelegaleducationfoundation.org/wp-content/uploads/2015/06/Role-of-Advice-Services-in-Health-Outcomes.pdf.
  5. The Commonwealth Fund. Mirror, Mirro 2017. Available from: https://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/ (accessed 19 September 2021)
  6. The Commonwealth Fund. Mirror, Mirror 2021. Available from: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly (accessed 19 September 2021)
  7. Royal College of General Practitioners. College sets record straight on face-to-face GP appointments. August 2021. Available from: https://www.rcgp.org.uk/about-us/news/2021/august/college-sets-record-straight-on-face-to-face-gp-appointments.aspx (accessed 19 September 2021)
  8. The Health Foundation. The UK spends less on capital in health care than other comparable countries. 2019. Available from: https://www.health.org.uk/news-and-comment/charts-and-infographics/the-uk-spends-less-on-capital-in-health-care-than-other-comp (accessed 19 September 2021)
  9. Papanicolas I, Mossialos E, Gundersen A, Woskie L, Jha A K. Performance of UK National Health Service compared with other high income countries: observational study  BMJ  2019;  367 :l6326 doi:10.1136/bmj.l6326

Why MPs and journalists need to speak to their local general practices

The UK’s MPs and journalists repeatedly say they want “GPs to get back to work”. But instead of asking this, they need to speak to staff in their local general practices to understand what the issues are that are causing problems for patients in gaining access primary care services, whether via a face to face appointment or by telephone. The number of GPs per person in England has declined in recent years. At the same time, the volume and complexity of care has increased steadily year-on-year. These problems have been compounded by the rebound in primary care activity following an initial fall at the start of the Covid-19 pandemic. Many GPs report that they and their teams are now dealing with a record level of work.

In this context, asking GPs to “get back to work” is insulting for them and their teams. GPs made major changes in the way they work at the start of the Covid-19 pandemic to protect patients – with little additional support from NHS England – and are now struggling with long-term shortages of doctors and other staff, and unsafe levels of workload. If GPs and journalists spoke to the staff in their local general practices, they would understand these issues better and also be more aware of potential solutions. Better-informed MPs and journalists might then actually be able to apply pressure on the government to urgently address the many problems that face NHS general practices in England, and bring an end to the culture of “sticking plaster solutions” that NHS England has offered in recent years.

Consent for covid-19 vaccination in children

Now that covid-19 vaccination of children in the UK is starting, it is essential that the legal basis of consent for a medical intervention in this group are well understood

A Court of Appeal ruling on 17 September 2021 overturned a previous High Court ruling, and decided that parental consent is not needed for children under 16 to take puberty blockers. This reaffirms, again, that the responsibility to consent to treatment depends on the ability of medical staff to decide on the capacity of under 16 year olds to consent to medical treatment.

The timing is auspicious. Just a few days before, the four UK Chief Medical Officers recommended that all healthy children aged 12-15 should be “offered” a single covid-19 vaccine, with a booster likely in the Spring 2022. Until now, the only children in this age group offered a vaccine have been those with certain medical conditions, or those living in a household with a clinically vulnerable adult. With a mass vaccine campaign for children now starting, the issue of consent for vaccines in this group has been headline news.

Reaching the decision about vaccinating 12-15 year olds in the UK has been an interesting process. The Joint Committee on Vaccination and Immunisation (JCVI) have deliberated, awaiting evolving evidence, and have scrutinised the data available purely on a risk benefit basis for the vaccine itself. The chief medical officers looked at wider effects to society, and given that modelling suggests that vaccination of 12-15 year olds can save so many lost days of school, infections and associated transmission, they recommended vaccination to the government, but leaving the final decision to politicians.

Now that covid-19 vaccination of children in the UK is starting, it is essential that the legal basis of consent for a medical intervention in this group are well understood by parents, carers, health professionals—and most importantly by children. Teenagers who are aged 16 or 17 are deemed under English law to be able to give their own consent for vaccination. But what about 12-15 year olds?

Ideally, for children who are aged 12-15, covid-19 vaccination would be given with the approval and support of their parents. This is likely to improve children’s confidence in covid-19 vaccines, and help ensure a high and rapid take-up of vaccination. With the vaccine programme due to start in schools before the end of September, parents are being sent out consent forms, along with NHS information leaflets. Explaining such a finely balanced decision in child friendly terms will be challenging. A survey by the UK Office for National Statistics reported that around 90% of parents were in favour of vaccinating children. Surveys also show good confidence in covid-19 vaccines among children and young adults (but usually at a lower level than among older people).

But despite high overall support for covid-19 vaccination, there will be families where children and parents may have very differing opinions about its risks and benefits. For example, some parents may be strongly opposed to covid-19 vaccination, but their child may have a different view. The opposite situation is also possible whereby the parents are in favour of vaccination but the child is opposed to vaccination.

In such circumstances, the NHS and the responsible clinicians have to decide if the child is competent to make their own decision about covid-19 vaccination. This is known as Gillick competence following a court case in the 1980s between Ms Victoria Gillick and the NHS about consent to treatment for children under 16. The court case eventually made its way to the House of Lords, which ruled that “As a matter of Law, the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.” The ruling is valid in England and Wales.

Whether a child is Gillick competent is assessed using criteria such as the age of the child, their understanding of the treatment (both benefits and risks) and their ability to explain their views about the treatment. If deemed to be Gillick competent, the child can make their own decision about a medical intervention such as covid-19 vaccination.

There may also be situations in which two parents disagree about covid-19 vaccination. If the child is not Gillick competent, then a decision needs to be made about which parent’s views take priority. In a court case in 2020 where two parents disagreed about vaccination for their children, the Judge ruled that vaccination was in the best interests of the child because this is what the scientific evidence suggests. In the court case, the judge (Mr Justice MacDonald) deferred deciding about any future covid-19 vaccination because of the “early stage reached with respect to the covid-19 vaccination programme.” However, now that vaccination has been approved by the UK government and is supported by bodies such as Public Health England, it is highly likely that a court would rule in favour of covid-19 vaccination where two parents had opposing views.

None of these issues are new, and the current HPV vaccination programme has tested many of the issues surrounding vaccination in this age group already. However, the scale and speed of the covid-19 vaccination may be far more contentious—particularly given the finely balanced risk-benefit profile, the small risks of myocarditis, and the vaccine hesitancy already noted in younger people.

It is important that parents, teachers, and healthcare professionals understand the risk and benefits of covid-19 vaccination for children, so that we can support them in reaching an informed decision. We need to respect the ability of our children, whose lives and education have been so greatly affected and disrupted by the pandemic, to reach their own conclusions given the evidence available. Where there is a disagreement between a child and their parents or legal guardians regarding any medical treatment, healthcare professionals must feel confident in judging Gillick Competence and the issues surrounding capacity to give consent.

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

Simon Hodes, GP Partner, Watford, UK, Twitter @DrSimonHodes

Stephen Marks, Consultant Paediatric Nephrologist, Great Ormond Street Hospital, London, UK

Competing Interests: We have read and understood the BMJ policy on declaration of interests. AM and SH are GPs and have supported the NHS covid-19 vaccination programme. We have no other competing interests.

Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

This article was first published in BMJ Opinion.

GPs should not be made scapegoats for political failings

A recent article in the Daily Telegraph article asked “If the GPs went on strike, would anybody notice?” The article claimed that no one would notice if GPs went on strike and the author suggested that making all GPs salaried, forcing them to work longer hours, would help improve general practice for patients. The author quoted “a now retired GP in his 90s from Bristol who continued doing locum work until five years ago,” who apparently said, “Many GPs are using covid-19 as an excuse for not providing good clinical services. Being able to opt out of night/weekend cover and only working two or three days a week have caused the demise of general practice to the detriment of patients.”

As GPs we have worked throughout this pandemic often face-to-face in the most basic of personal protective equipment (PPE), and we were disheartened to read this piece.

GPs and their teams have played an essential role throughout the pandemic. GP teams in England alone deal with over 300 million contacts each year. General Practices have been running community hot covid clinics, and supporting NHS 111 and the Covid Clinical Assessment Service (CCAS). We are supporting 5.5 million patients on NHS waiting lists, who are often in severe pain and in need of extra support, as well as supporting about 1 million patients with the effects of long covid, and adapting to new ways of working enforced by a global pandemic. In addition, our teams have delivered the majority of covid vaccinations thus far. We are currently being asked to recall our most clinically vulnerable patients for their third covid booster vaccination. All this has been achieved despite the proportion of the NHS budget spent on NHS general practice and the number of GPs per person both declining in England in recent years.

We are already seeing that any small reduction in GP access causes rapid spill over into Emergency Departments, so just imagine if there were no GP service at all. The NHS would collapse. When GPs began to pull back from the covid-19 vaccination programme because of the mass vaccine sites taking over, for example, the rate of vaccination slowed—especially in the hardest to reach groups—and complaints increased from patients unable to access vaccine appointments.

If we look at prescriptions, GPs and their teams issue a vast number every year. If another part of the NHS tried to take on this work, an army of people would be needed—doctors, pharmacists, and administrative staff. Many higher risk medications need careful monitoring and regular review. Patients on most regular medication also require medication reviews, checks (e.g., blood tests, measuring blood pressure) to monitor safe prescribing and prevent drug interactions, and to deal with queries and frequent shortages and changes of medicines. The efficient systems that GPs have developed for prescribing means that they issue many prescriptions that would be given by hospital specialists in other countries.

Moreover, every patient seen in secondary care generates a letter, often with requests for GP teams to follow up patients, monitor their treatment, arrange blood tests, or prescribe.

The work of a GP can be incredibly rewarding as we build long term relationships with people over years, and there is strong evidence for the benefits of continuity of care (for both patients and the care provider).  GPs are true “generalists” and the uncertainty of undifferentiated illness is stressful, especially when working remotely. GPs in the UK work at a higher level of intensity than elsewhere in Europe. GPs in the UK have the shortest consultation times in Europe, and UK GPs tend to see more than twice the safe recommended number of patients per day.

BMA appointment data show huge increases in activity over the past 18 months. Yes, there are more telephone appointments and fewer face to face appointments, but this is the same in all sectors of society—and the same for both community and hospital care. It should come as no surprise, or make headline news, because remote working is in line with direct government policy and is there to protect both patients and staff from a highly infectious and potentially lethal virus. It is especially important to protect the many vulnerable individuals we look after in general practice, in a time when there are over 30,000 covid-19 cases reported daily in the UK.

Despite political promises for an additional 6000 additional GPs in England by 2024, there has been a reduction in numbers rather than an increase. While there is a clear link between ratios of family doctors and life expectancy, the number of patients per practice is now 22% higher than it was in 2015, and the GP workforce has not grown with this demand. As a result, there are now just 0.46 fully qualified GPs per 1000 patients in England, down from 0.52 in 2015, which, when added to growing demand from the rising number of people living with complex chronic illness and poverty along with an ageing population, means that primary care is in a desperate situation. GP turnover is higher in deprived areas further exacerbating health inequalities.

Demand on general practice is increasing, while at the same time general practices are struggling to recruit staff. The current deepening GP crisis that we are facing is having widespread effects on patient care nationwide. The current crisis long predated covid-19, but the pandemic has highlighted the large cracks in the NHS. GP teams should not be made scapegoats for the political failings, under-funding, and shortages of essential staff, which are the root cause of the issue.

General practice is often described as the “Bedrock of the NHS,” and the NHS Five Year NHS View states that “if General Practice Fails the NHS Fails.” We must be mindful of that, and instead of blaming GPs for the current crisis, look at what can be urgently done to alleviate the crisis.

Simon Hodes, GP partner in Watford, GP trainer, appraiser and LMC rep. Twitter: @DrSimonHodes

Frances Mair, Norie Miller professor of general practice. Twitter: @FrancesMair

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.